ABSTRACT This discussion focuses on the difference between
educational objectives and outcomes. Both terms are used in nursing
education, many times for the same purpose, yet they are expressions of
different educational paradigms. A historical view of the development of
objectives and outcomes is provided as well as a description of each.
The discussion concludes with a demonstration of formats for developing
Key Words Objectives--Outcomes--Metacognition--Teaching and
COMPREHENSIVE INITIAL AND ONGOING EDUCATION IS ESSENTIAL FOR ALL
REALMS OF NURSING PRACTICE, EDUCATION, AND RESEARCH. Whether the process
takes the form of in-services for established nurses, academic sessions
for nursing students, multidisciplinary professional research
presentations, or patient teaching, education is a vital part of the
nursing role. Traditionally, nurses have been taught to start all
educational or teaching/learning sessions by stating the objectives, a
practice that provides a clear understanding of the purpose of the
session and serves to clarify the teacher's expectations. The
learner's changed behavior is evaluated after the completion of the
session to demonstrate that learning took place. As stated by Rankin and
Stallings (2001), "Objectives describe behaviors that the learner
will perform to meet a goal" (p. 240).
Our current, economically driven health care environment focuses on
outcomes of care. In response, nursing education has interposed outcomes
of learning for objectives of teaching (Morin, 2007; Partusch, 2007).
The educational literature has also long spoken to outcomes rather than
objectives. The central focus is to redirect the teaching/learning
process and bring about a closer link to the learner. This also aligns
better with professional practice, where outcomes promote quality
improvement (Glennon, 2006).
This shift in thinking, from objectives to outcomes, has been cited
as a paradigm shift and, indeed, there are theoretical differences. Many
nurse educators who are not fully aware of the underlying impetus for
the change wonder why wording has changed in courses that have no change
in context or content (Morin, 2007). Some see this trend as a linguistic
game, with the word outcome substituted for the word objective in order
to maintain political correctness (Schwarz & Cavener, 1994).
Prideaux (2000) called this phenomenon "the emperor's new
clothes" in medical education.
Relevance How we frame what we, as nurses, teach and what our
recipients (other nurses, professionals, students, or patients) learn
should be more than just a linguistic exercise. It affects the
teaching/learning process and ultimately affects application to patient
care. Because of its importance and societal contribution, the framing
of the teaching/learning process needs theoretical thought.
Reviewing the standard definitions of the words objective and
outcome further reveals the essential difference between the two
concepts. An objective speaks to the process and the goal. Therefore, it
is teacher and student focused. An outcome, a final product or end
result, speaks to the goal, so its focus is the student, because
learning is the goal for the student.
The obvious reason that objectives or outcomes still exist and
persist in education is that they are thought to be parsimonious enough
to capture the complexity of the teaching/learning process. Many
educators believe they have the simplicity and practicality needed for
mapping out and evaluating understanding of what is to be learned.
Historical Development For many years, objectives were presented as
the essential foundation of any educational endeavor in nursing
education and were elevated to the position of "guiding light"
for both the process of teaching and the end result of the learning.
Objectives were used for all activities that took place within a
classroom, course, session, or curriculum (DeYoung, 2003). "Well
defined learning objectives ... are stated so that expectations are
clear to the student" (de Tornyay & Thompson, 1982, p. 150).
Education has used objectives for student learning since Tyler's
(1949) landmark book encouraged educators to develop objectives to frame
their teaching (Reilly & Oermann, 1999).
According to Prideaux (2000), Tyler intended to keep objectives
broad in nature; they were modified by others to conform to behaviorism
and standardization. The form in which objectives emerged was usually a
three-part statement that included the behavior, condition, and standard
of the teaching/learning process. Educators adapted objectives and even
prepackaged them for educators to avoid errors in their development
(Prideaux). The criteria that heralded a good objective were specificity
and measurability, and these have been carried over to outcome
Action verbs outlined by Bloom and colleagues were used in
composing objectives to specifically describe expected behaviors of the
learner. Bloom's taxonomy (Bloom, Englehart, Furst, Hill, &
Drathwohl, 1956) uses behavioral terms to divide learning into leveled
achievements, from knowledge acquisition (understanding) to the
synthesis (creating) of new ideas (Krathwohl, 2002). Behavioral terms
were further categorized into three domains (cognitive, psychomotor, and
affective), underscoring the presence of the art, science, and practice
of nursing. Gagne (1970) also described objectives as the second event
in the nine steps to instruction, thus reinforcing the need for them.
Objectives presented a method to logically organize a teaching
session or course and provided criteria for evaluation that allowed for
grading justification (Novotny & Griffin, 2006). Using objectives
served its purpose well, organizing the teaching/learning process while
the discipline of nursing was in its growing stage of intense curriculum
development (Parker, 2005). Developing and meeting objectives were
important; objectives were used by educators and accrediting
organizations to evaluate an individual's or organization's
teaching effectiveness (Billings & Halstead, 2009).
Anderson et al. (2001) suggested that a higher learning domain,
metacognition, be included to encompass aspects of critical thinking
spurred by reflection. Metacognition is used along with the terms
factual, procedural, and cognitive to encompass all aspects of knowledge
acquisition. Investigation of methods to enhance metacognition is needed
in nursing education to foster appropriate knowledge development and
deal effectively with the information-driven health care environment.
Teaching methods to increase metacognition, such as concept mapping,
have been shown to be successful (August-Brady, 2005).
Paradigm Shift As the health care environment changed to a forum
regulated by cost expenditure versus human risk, outcomes became more
important. In the clinical arena, outcomes are evaluated in terms of
dollars and cents, health achievement, patient safety effectiveness, or
educational productivity, and the question is asked: Does the outcome
justify the resources used? Outcome-based education (OBE) began in the
1980s and grew in-popularity in the 1990s (Spady, 1988; Harden, Crosby,
Davis, & Friedman, 1999). It has its historical roots in
competency-based education, which originated in the 1960s (Schwarz &
Cavener, 1994). Harden, Crosby, and Davis (1999) used the term
performance-based education, where the emphasis is the product and focus
is always the end result. Spady described OBE as "a way of
designing, developing, delivering, and documenting instruction in terms
of intended goals and outcomes" (p. 2).
Nursing education has adopted outcome expectancy, or OBE, which
considers the learning experience as delivering the product or knowledge
needed by the student, patient, or nurse. The process is no longer the
priority in the learning; this, hopefully, has opened the door to many
creative teaching methodologies. The outcome, what the student, patient,
or colleague will cognitively, skillfully, or affectively demonstrate by
the end of the experience or lesson, is most important.
It is important to note that the paradigm shift removed the focus
from the teacher and extended the responsibility of learning to the
learner. One criticism is that this paradigm shift has the potential to
squelch learning for pure knowledge and personal growth, and sometimes,
not always, implicates that the outcome must be directly applicable.
Morin (2007) provides a good explanation of the current general
understanding of the difference between objectives and outcomes, stating
that "outcomes reflect the students' performance in relation
to objectives" (p. 251).
In a simple analogy, OBE can be compared to a vacation. An
outcome-based trip would choose the destination first, then research the
modes of transportation to get to the chosen point. A vacation planned
on objectives would plot the specificities of the route as well as the
mode of transportation.
Operationalization of the Paradigm So how do we operationalize the
difference between behaviorally written objectives and learning
outcomes? The differences are slight in language but can represent a
large change in conceptualization, depending on the educator's
understanding and the educational culture in which they are used.
Both objectives and outcomes use behavioral terms and extend the
principles set forth by Tyler (1949) and others (Bloom et al., 1956).
The lead-in sentence is usually altered in a teaching/learning session
from "the student will" for objective writing to "at the
end of this session, the student will be able to" for outcome
formatting. As Prideaux (2000) states, "It is difficult to explain
the difference between a significant and worthwhile objective and a
well-written and well-defined outcome" (p. 169). Outcomes and
objectives are both still expected to describe the learner, the
behavior, and the content.
Changing from objectives to outcomes is truly more of a conceptual
than an operational change. Some nurse educators have just switched
words and not thought processes. Others believe that neither objectives
nor outcome gives us the freedom needed to encourage learners to think
critically. Neither captures the "aha" moments of learners or
the creativity that is encouraged in the class and clinical arenas. The
current learner-centered paradigm of nursing education calls for a more
fluid framework than either objectives or outcomes can provide. Outcomes
are slightly less restrictive in the learning environment, a positive
move toward an educational process that is more emancipatory (Freire,
1970; Schreiber & Banister, 2002).
Future Paradigms Because people rarely learn something using just
one learning domain, the use of objectives in nursing education was
rightfully questioned by forward thinkers such as Diekelmann (1997) and
Bevis and Watson (1989). Also, the idea that learning or knowledge
acquisition can always be demonstrated in behavior is not realistic.
Diekelmann, Bey,s, and Watson understood that all learning is not
displayed in behavior, and that by predetermining learning with
objectives or outcomes, we may be squelching the depth and breath of the
learning experience. The notion that a piece of information can be
categorized in a knowledge level from simple recall to synthesis makes
it simplistically exclusive. Objectives and outcomes tend to keep
learning linear and isolated in categorizations hinged on observable
behaviors. In the behaviorist paradigm, the behaviors the student
displays that are the testimonial that learning took place may not
capture the thought processes or thinking ability of the learner.
It is difficult, at best, to package the human intellect into a
modifiable mold for convenience in grouping, evaluating, and justifying
what is being taught or presented, or what the learner carries forth
from the experience. Nursing education, as a practice discipline, is
even more fraught with categorization difficulties because it has an
application component displayed in the practice. The application of
knowledge does not always coincide directly with the theoretical portion
sequentially because of the holistic nature of the profession. The
nursing art of caring and caring for is much greater than the
educational parts when they are separated into components (Dunn, 1991).
Can we ever predict what is learned? Can we assess what is learned
from overt behavior? Can we state exactly what we are going to teach?
Maybe we can state the concepts or topics that we will focus on in a
session, but what we teach is perceived differently by each learner, and
what is learned from different perceptions is not always categorically
definable. Knowledge is a complex concept in itself, but in order to
turn out safe practitioners and to provide ongoing education in the
discipline of nursing and to provide safe information to the public,
specific knowledge must be mastered at some level of comprehension. That
mastery of information (for lack of better description) must be
measured, which is what is attempted through outcome development.
How to Develop Learning Outcomes So, with all that being said,
young educators still need to know bow to write learning outcomes as
opposed to objectives. Harden, Crosby, and Davis (1999) listed criteria
that outcomes should meet: reflect the mission and be clear, specific,
manageable in number, appropriate for the level of the learner,
progressive, and related.
Nursing education has available several good resources that explain
how to write outcomes to meet these criteria. (Examples are provided in
the Figure.) One, from Florida State University (2007), provides
instruction by using the A-B-C method. The "A" stands for
antecedent or the learning activity; "B" stands for behavior
or the skill or knowledge being demonstrated; and "C" stand
for the criterion or the degree of acceptable performance. (Example A in
the figure is compared to an objective in Example B.)
Other outcome instructions include a slightly different three-step
process that includes verb, object, and context (Kahn, 2003). Here the
criteria are not stated specifically. Some instructions even provide a
template to assist the educator to develop appropriate learning outcomes
(Florida State University, 2007). An example of an adapted template,
which includes all the mentioned components of a learning outcome, is
shown in example C in the figure. To check your outcomes, ask this
question: Is it observable and measurable, achievable, and meaningful?
(California Department of Health Services, 1998).
Formatting any abstraction always runs the risk of stifling
creativity, so a conscious effort must be made to keep the goal of the
outcome in mind. What is the product that you want to produce at the end
of this learning experience? Until an entirely new paradigm takes hold
in nursing education, outcome-based education needs to work for those
educators who are currently entrenched in nursing education.
Understanding historical development, underpinning philosophies,
definitions, and structural mechanisms helps empower educators by
developing self-efficacy in the educational process.
About the Authors Ruth A. Wittmann-Price, PhD, RN, CNS, CNE, was
assistant professor and coordinator for the education track at Drexel
University, Philadelphia, Pennsylvania, when this article was written.
She is now head of the nursing program at Francis Marion University,
Florence, South Carolina. Brian J. Fasolka, MSN, RN, CEN, is an
assistant clinical professor at Drexel University College of Nursing and
Health Professions. Contact Dr. Wittmann-Price at
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Figure. Writing Outcomes
(A) By the end of this session the learner will be able to:
(B) Demonstrate sterile Foley catheter insertion (C) 100% of the
time in clinical.
This learner will:
demonstrate (verb) sterile Foley catheter insertion in clinical by
return demonstration (content or context).
Antecedent / By the end of this session
Learner / the nursing student will
Verb describing behavior / demonstrate
Content / Sterile Foley catheter insertion
Context / in clinical
Criteria / 100% of the time